EPI in Dogs

What is EPI (Exocrine Pancreatic Insufficiency) in Dogs?

Canine EPI (Exocrine Pancreatic Insufficiency) is simply known as the inability to produce sufficient pancreatic enzymes (Amylase, Protease & Lipase) to digest fats, proteins & carbohydrates. This lack of or difficulty in digestion leads to poor absorption of nutrients which commonly causes extreme weight loss or wasting over time despite a normal or increased appetite. Any breed can develop EPI and the condition can occur at any stage of a dog’s life. If left untreated, EPI is fatal.

The major cause of EPI in dogs appears to be the loss of functioning pancreatic cells. Chronic pancreatitis and/or inflammation of the pancreas organ can also cause EPI. The condition can be present from birth, inherited (genetically) or acquired at any time as the result of pancreatic inflammation, infection or even injury.

Some canine EPI symptoms may include:

• Unexplained weight loss, wasting away
• Increased or voracious appetite
• Frequent diarrhea
• Foul-smelling, greasy, yellow and/or cow-patty like stools
• Food seeking or aggression behaviors
• Gas or bloating
• Poor fur or coat
• Changes in personality
• Reduced activity, listlessness

An EPI diagnosis can be obtained through a TLI (8 to 12 hour fasting) blood test performed by your veterinarian. Many people successfully self-diagnose EPI in their dogs which can save money, but having an official exam, testing & diagnosis from your veterinarian can be very beneficial in ruling out or even finding other conditions that may be present.

Treatment of EPI in Dogs

Canine EPI is not curable, but can be successfully managed allowing the dog to live a long & happy life.  However, the dog owner must learn the proper administration & management of:

• Porcine Pancreatic Enzymes (added to every meal)
• Food
• B12 supplementation (required by a majority of EPI dogs)
• Antibiotics if needed for SID/SIBO
• Follow-up care

Porcine Pancreatic Enzymes

Porcine based, pancreatic enzymes (also known as Pancreatin, USP) containing the highest levels of Amylase, Protease & Lipase are standard of care for treating EPI in dogs and must be added to every meal that is consumed by the dog. This is sometimes referred to as ERT (Enzyme Replacement Therapy). See dosing and incubation below.

These pancreatic enzymes (Pancreatin) are replacing what the pet’s damaged pancreas cannot produce and will allow for proper digestion & nutritional absorption of food to take place in the GI tract of the dog or cat.

Pancreatin comes in various strength levels as listed within the USP (United States Pharmacopeia) Monograph which is an independent scientific organization that sets purity, strength and identity standards for medicines, food ingredients, and dietary supplements.

Commercially available Pancreatin typically comes in strengths of 4x, 6x, 8x and 10x which is the strongest grade available.

The most effective pancreatic enzymes to treat EPI in dogs contain a 10x potency of Amylase, Lipase & Protease and is found in most Rx brands and two OTC (over-the-counter) brands available in the United States.

Pancreatin 6x and 8x products are also available in the U.S. market, but these products are not stronger than Rx brands, which is a common misconception in the EPI dog community. The reduced potency of these products requires per-cup dosing versus per-meal dosing for Rx brands that have a higher strength.

The majority of long-established U.S. Rx brands contain a 10x potency and one Rx brand utilizes a 9x potency in their formula.

As an example, the following table represents an actual internal 10x potency specification for one of the largest Rx enzyme brands in the U.S. (company/product name withheld):

NLT = Not Less Than, Meets USP = Meets USP Monograph Specifications

Per the USP (United States Pharmacopeia) Monograph specifications for Pancreatin USP, Pancreatin contains, in each mg not less than 25 USP Units of amylase activity, not less than 2.0 USP Units of lipase activity, and not less than 25 USP Units of protease activity. Pancreatin of a higher digestive power may be labeled as a whole­-number multiple of the three minimum activities (i.e. 4x, 6x, 8x & 10x).

When you take each of the enzyme potencies in the above table that are manufactured meeting the specifications for Pancreatin 10x, as listed in the USP Monograph and multiply these by the average Rx label dose of 2.8 grams or 2800 mgs (i.e. Amylase 250 x 2800, Protease, 230 x 2800, Lipase 50 x 2800) you come up with enzyme potencies of Amylase: 700,000 USP units/mg, Protease: 644,000 USP units/mg and Lipase: 140,000 USP units/mg that are found in a 2.8 gram (~1 teaspoon) dose of this Rx brand of enzymes.  While some firms may ‘tweak’ their individual formulas, most of the Rx brands contain these enzyme levels in their products. Many people ask why the potencies on Rx jar labels appear lower?  This is because Rx brands expose their products to accelerated stability testing in laboratories under varying degrees of temperature, humidity & time to make sure the jar contents (enzymes) remain stable under the temperature stresses of transportation & storage and the final potencies (after testing) represent the ‘minimum’ enzyme levels that are present in the product at the point of expiration and this is the industry accepted standard for properly listing enzyme potencies.  Most jars are consumed within the first year after manufacture so these lower, minimum jar-label numbers should mean little to the dog owner and the actual potency numbers stay much higher if the jar is not stored in extreme temperatures long-term. What is important to understand though, is the above 10x enzyme levels are the actual potencies present in an average Rx brand of enzymes at the time of packaging. This is important for people to understand in correcting the common misconception that Pancreatin 6x and 8x products are stronger than Rx brands.

While lower strengths of Pancreatin (i.e. 6x or 8x) can certainly work for many EPI dogs, using a higher potency of enzymes can produce better digestion with reduced dosing due to consistently higher enzyme levels being present in a smaller standard dose. The stronger the enzymes, the more proteins, fats and starches can be metabolized in a given meal. Reduced dosing using a stronger enzyme can also lessen acidity levels in the meal which can reduce acid reflux suffered by many pets receiving enzyme replacement therapy.

It should be noted that the pet owner can try pancreatic enzymes without having an official diagnosis (if EPI is strongly suspected) by simply purchasing one of the OTC (Over-The-Counter) products listed on our Enzyme Brand Comparison and Emergency brands pages. Especially if you are dealing with a dog that has lost a majority of it’s body weight. The risk of side effects with pancreatic enzymes is very low versus the possibility of losing the dog while one waits for an official EPI diagnosis.

Pancreatic enzymes with an ultra-high (>10x) levels of Lipase are called Pancrelipase, USP and this potency is reserved for human EPI prescription medications such as Creon, Pertzye & Zenpep which can also be used to treat EPI in dogs in those countries where regular pancreatic enzymes are not readily available (i.e. Australia, India etc.).  However, please note these human EPI medicines are specifically formulated to work within the human digestive tract and many times do not work as well in dogs. For example, Creon 10000 is a popular strength used in EPI dogs, but the dosing is tricky and you must find what works through trial & error.

Some EPI dog enzymes may list Pancrelipase as the active ingredient on their jar, but this is incorrect. Again, Pancrelipase contains ultra-high levels of Lipase reserved only for human Rx drug use and these levels of Lipase are much higher than what is actually present in EPI dog supplements.

Plant based digestive enzymes found on the internet and vitamin shops should be avoided. While these products may be advertised for EPI use by unscrupulous firms, plant-based enzymes are not strong enough to successfully treat EPI in dogs.

Proper Pancreatic Enzyme Dosing

One of the biggest mistakes a new EPI dog owner can make is to over-dose the enzymes being given to a newly diagnosed dog.

Enzyme label directions are written based on the potency of a given enzyme brand.

Rx and OTC brands with a 10x potency are dosed 3/4 tsp to 1 tsp per-meal.

Over-the-counter 6x and 8x products have a weaker potency and are typically dosed 1/2 tsp to 1 tsp per-cup of food.

It is best practice to always use the least amount of enzymes possible while still obtaining the proper, therapeutic benefit.

Should you need to increase the enzyme dose, only do so in 1/4 teaspoon increments. Then stay at this dose for 4 to 5 days and then check the stools. If they are normal or near normal, then stay at that dose.

Smaller dogs (and cats) that consume a cup or less of food per meal, can many times use less enzymes per feeding. We have found that meal sizes of 1/2 cup of food can easily be managed with 1/4 tsp (or less) of enzymes sometimes.

One administrator on this site has an EPI cat that requires only 1/4 tsp of a 10x potency brand of enzymes mixed into a 3 ounce can of Fancy Feast (Tender Beef Feast Classic Pate) brand of cat food. She has found that the ‘pate’ forms of cat food always work best for mixing the enzymes.

Having spoken with several Rx enzyme brands during research for this site, the typical label directions of 3/4 tsp to 1 tsp per-meal for a dog is a good starting dose for meals of up to 2+ cups of food in total volume. However, every EPI dog is different and you may end up with a slightly lower or higher dose for your dog.

Interestingly, we spoke with a QC director from one of the major Rx enzyme brands who stated they can start to see difficulties in EPI dogs that are fed more than 2.5 cups of food in one sitting.  Apparently, it becomes difficult to judge the correct amount of enzymes needed to metabolize larger amounts of food above 2.5 cups in volume.

As a result, most EPI dogs do better with smaller, more frequent feedings of 3x per day if possible.

The dog food must always be moistened, but only contain enough moisture to allow the enzymes to stick to the food particles to facilitate proper, thorough mixing. Once the enzymes are mixed into the food, one should allow the food (with enzymes) to sit at room temperature for 15 or 20 mins before feeding. Never microwave food that has been treated with enzymes, as this can destroy the enzymes.

It is sometimes human nature to use more than what is needed and this should be avoided when dosing enzymes. More is not always better and there is a fine line many times. Too little enzymes can cause bad stools and using too much can cause bad stools as well.

Like most things when dealing with EPI, you will need to find the dose per-meal that works best through trial & error and then stick with it.  EPI dogs (and cats) love consistency and do well once you find and adhere to a daily feeding routine that works.

Many people make the mistake of constantly changing the enzyme dose when first starting out if they see bad stools. You must stay at a given dose for at least 4 days to see what the results are.

When making any changes (enzyme dose, food etc.), you must wait at least 4 to 5 days to see what the results of those changes are.

This is because any changes made can take this length of time to move through the digestive system revealing what the true outcome is.

Once pancreatic enzymes are introduced with every meal, stools can begin to improve within as little as 24 to 48 hours or you may see gradual improvement over the next 5 to 7+ days if the dosing is adequate. This can vary with every dog and can be heavily dependent on whether SID/SIBO is present and if antibiotics are being administered.

Improved stools are the ultimate indicator that food is being digested and proper nutrition is being absorbed. Take notes on what enzyme dosing and food preparation has worked best to improve your pet’s stools. Once good stools are achieved, you want to remain consistent and not deviate.

Please review this interesting article by Purina on dog poop which contains a helpful chart in helping to grade your dog’s stools. Your dogs stools should be compact while also being moist and easy to pick up as indicated by #2 and #3 under “IDEAL” in their dog poop consistency chart.

Incubation of Pancreatic Enzymes

All U.S. brands of EPI dog enzymes require the user to mix them into moistened food and then allow the food (with enzymes) to sit at room temperature for a minimum of 15 to 20 minutes before feeding. This is known as incubation.

The dog food must always be moist, but only enough to allow the enzymes to stick to the food allowing proper, thorough mixing. Never microwave food that has been treated with enzymes, as the heat will destroy the enzymes.

One should mix the enzymes + food very thoroughly, creating a homogeneous mixture of enzymes and food.

This is the true & tried method for preparing enzymes and should be followed for each meal, especially in the beginning when it is crucial to get the dog stable as soon as possible.

Enzymes are naturally high in pH (acidity), especially when they are first introduced to moisture. This natural acidity is greatly reduced when you allow the enzymes to incubate in the food at room temperature.

This acidity is thought to play a role in some dogs that experience irritation of the gums or mouth sores, so incubation can be quite important. However, it is rare for dogs to actually get mouth sores when enzymes are properly dosed and incubated.

Some people find that their dogs actually do better when they allow the food + enzymes to incubate for even longer periods of 30+ minutes and some let it sit for as long as an hour.

Allowing the food to sit with enzymes is also thought to help it reach a more digestible form and this makes perfect sense when you are dealing with a dog that already has a distressed GI system.

The pet owner will need to experiment to determine the incubation time that works best for their dog.

Alcohol based vs Acetone based enzymes

Pancreatic enzymes are produced (i.e. extracted) from porcine pancreatic glands via two distinct production methods that are very easy to identify.

The first method is extraction via alcohol (Isopropyl Alcohol to be exact) which produces an enzyme that has a more natural and/or neutral odor. This is the go-to-grade used by reputable EPI dog enzymes, as this odor profile makes it the most palatable to dogs, cats and their owners. All of the products listed on our Enzyme Brand Comparison page are manufactured using alcohol as the preferred production method.

The second method is extraction via acetone (paint thinner). Pancreatin manufactured this way ends with a product that has a strong odor resembling what has been best described as something approaching cat-urine. Such a product may be acceptable for tablet or capsule applications in human digestion supplements, but most dogs simply do not accept this odor once mixed into their food.

Products that contain an acetone odor are not recommended, as these are generally not palatable to most dogs long-term. Such acetone-based products also have demonstrated quality concerns since the majority of these acetone-based enzymes originate from factories in China that have less stringent quality control standards versus U.S. and EU made pancreatic enzymes.

Acetone based enzymes manufactured in China are also many times sterilized using a process called Gamma Radiation. This sterilization process uses low-dose radiation to treat the finished product to achieve safe bacteria & virus levels for consumption. These factories must use this sterilization method because their facilities and production methods are not as advanced as factories located in the U.S. and Europe. China is the only nation that uses this sterilization process which has been banned by many countries due to safety concerns.

As of late, some 10x products have appeared in the U.S. marketplace that contain this acetone smell yet state they are made in the USA. This is not possible, as no U.S. manufacturer of pancreatic enzymes (pancreatin) uses acetone in their production process. This demonstrates that these firms are not being truthful with their product labels when it states it is made in the U.S. The quality of such products is suspect at best and they should be avoided for the safety or your pet.

As a result, it is suggested that you only utilize enzymes with a neutral odor characteristic that have been manufactured via alcohol. Following such practice can make the introduction of enzymes much easier to a sick dog that is already in great distress and in need of immediate help.

Hiding Enzyme Smell

No matter what we do, some dogs are just very picky and will simply not consume their food with enzymes mixed in. While they may grow out of this, there are steps one can take to alleviate this or make the food + enzymes more palatable.

First, be sure that you are NOT using an acetone based pancreatin. Acetone based pancreatin has a very distinct (cat-urine) like odor which many dogs will not accept. Use only reputable (non-acetone) brands like those listed on our Enzyme Brand Comparison page.

Be sure you are incubating the food + enzymes correctly. One should incubate the food at least 20 mins at room temperature and this length of time can be increased substantially if needed.

Also be sure that you are using the smallest dose possible, as smaller dosing will be harder for the dog to detect after thorough incubation. If you are using a 6x or 8x product, consider using a stronger enzyme that will allow use of a smaller dose while still facilitating proper digestion.

You can also use toppers on the food such as sardines, parmesan cheese, tuna or even gravy.

Some find success with feeding on a flat plate, as having the sides open can direct some of the odor away from the dog’s nose.

Enzymes are naturally caustic and it can be very helpful to use a stainless steel bowl that will not absorb enzyme odors over time.

EPI dog owners should also know there is a generic drug called Mirtazapine in pill form that is available from compounding pharmacists that has been shown to increase appetites in dogs. This may be useful for those dogs that are exceptionally low in weight and at risk of death. Please discuss this with your vet in deciding whether this medication might be an option for your EPI dog.

For cats that specifically have trouble eating food treated with enzymes, one of our site administrators has had great success with a drug called Mirataz ointment and their cat that has EPI. Mirataz is an FDA-approved medication for the management of weight loss in cats.  It is available from your veterinarian with a prescription.  The medication is an ointment that is applied to the inside of the cat’s ear and it stimulates their appetite making food (with the enzymes) more appealing or palatable. Our colleague felt this medicine was very helpful in getting her cat to accept the food + enzymes and begin to gain weight. Please discuss this with your vet in deciding whether this might be an option for your EPI cat.

Pancreatic Enzyme Tablets

Some of the Rx enzyme brands also offer tablet versions of their products. While some dog owners find that tablets work well for their EPI dogs, a majority do not have success using them. If you must use them until the powder is obtained, try crushing multiple tablets first and then mixing them into moistened food as you normally would with the powder. In the end, powders seem to be a much better choice over tablets for achieving stability in EPI dogs.

Bovine (Beef) based Pancreatic Enzymes

Bovine based pancreatic enzymes are generally not a viable product to treat Canine EPI long-term. These products are not standardized to contain high enough levels of Amylase, Protease & Lipase to be as effective or affordable as porcine based enzymes. There is one mass produced brand that does have therapeutic levels of the 3 enzymes, but the levels are still not high enough to keep an EPI dog stable and should only be used in an emergency situation.

Some people feel their dogs have become allergic to porcine based enzymes, but this is very rare and many times can be linked to temporary allergies and reactions that have formed from poor nutritional absorption during EPI before diagnosis. This can clear up over time as the dog gets healthier through enzyme use and proper nutritional absorption.

Raw Pancreas

Raw Pancreas (in place of powdered enzymes) from beef or porcine glands is another option that some people report having success with. However, due to the low-availability of raw pancreas it is recommended to get your dog stable using one of the brands of powdered enzymes first before experimenting with raw pancreas. This is especially true if dealing with a dog that has lost a majority of body weight. While powdered enzymes are both standardized & more readily available, raw pancreas is actually hard to find and there is no way of telling what level of enzymes are present in a given serving. For these reasons, many people find that while they can sometimes supplement raw pancreas into the dog’s diet, it is not a viable treatment in taking the place of powdered, pancreatic enzymes. People also report that there are vast differences in the quality of raw pancreas between available sources which can only complicate matters further. Handling raw organs harvested under unknown processing standards can also present the risk of introducing illness to your household. However, if you reside near a beef or porcine processing farm or plant that can legally distribute organ meat, then raw pancreas may be an option for you.

Capsules

Some pet owners who have experienced difficulties with getting their pets to accept enzymes mixed into food, have found success with placing the enzymes in gelatin capsules first and then administering them to the dog before or during meal time.

Gelatin capsules come in various sizes of 000, 00, 0 and 1. For reference, capsule size 000 is a little longer than a U.S. Quarter in size and can hold close to 1/2 tsp of enzyme powder. You will need to find the capsule size that works best to hold the amount of enzymes your dog needs to consume with a given meal.  For example, if your dog requires 1 tsp of enzymes with each meal, then you could fit close to this amount in 2, size ‘000’ capsules.

Gelatin capsules can be found on many websites, including Amazon.

Granulated vs Fine Powder

Pancreatic enzyme brands typically come in two forms, granulated & fine powder. Enzyme brands that are granulated go through an extra manufacturing step to achieve this granular form which can make the product easier to handle and result in less dust during food preparation. Powdered enzymes are more of a fine particle size and can be spread in the air during handling. This can sometimes be of concern for people with lung conditions and those who might otherwise be allergic to enzyme particles that become airborne during handling & food preparation. While there are differences, both versions seem to work equally well for dogs and cats once mixed into daily meals and consumed.